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Learning the ropes, so to speak

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Name: Julian
Gender: male
Age: 32
Location: Mexico City
What does CBT mean?

Geez, CBT could mean all sorts of things, depending on the context. It could stand for Cognitive Behavioral Therapy, something the good doctor knows a great deal about. It could also stand for Computer Based Training, but why in the world would you be asking Dr Dick about that? Let me see what else…CBT also stands for “Cock and Ball Torture”.

Yeah, that’s it! That’s what you want to know about, huh Julian — you little pervert, you. Good for you!big-balls

There are all manner of torture techniques for your cock and balls Slapping, Squeezing, Pinching, Bondage, the use of weights even tickling can be a form of torture. A dude’s package can withstand a fair amount of torment. But dolling out professional grade torture is not for the amateur. The dominant (as opposed to the submissive) really needs to know what he or she is doing. Carelessness can lead to severe injury.

In most cases, “torture” is really mostly “play”. One’s cock and balls are simply tugged on or stretched out, maybe with some weights. There’s cock and ball bondage too — the family jewels trussed up like a thanksgiving turkey, don’t cha know. And that’s just the beginning. Imagine what you could do with your mother’s old clothespins. See, now you’re putting two and two together!

Oh, and the “T” word doesn’t necessarily stand for torture. It can represent a full range of play — from tickling and teasing to torment and torture.

If you’re interested in investigating the pain/pleasure of cock and ball torture for your self, Julian, here’s a safe way to start. Begin by experimenting with different sensations. Look around the house for things you can brush or rub against your cock and balls. Start with something soft like a silk scarf. Progressively work your way to something with a rough texture, like a scrub brush. You will also notice that the sensations are different when your dick is soft as opposed to when it is hard.

curiosity_WM_1024x1024Try a hollowed-out, cylindrical loofa sponge. Get it good and wet, and slip it over your cock and try jerkin’ off with it. Rubber bands can be applied to your cock and balls. Not only for the constriction sensation, which is delightful in itself. But you can also snap those puppies for some delicious pain.

Lots of pervs like cock and ball spanking. You could try your hand at this, so to speak. Or you could employ a kitchen wooden spoon or spatula. They work nicely too. Prickly things like a fork can be used to scrape or drag over your cock and balls. Poke them lightly if you like. Be careful though; you do not want to break the skin and draw blood.

Cock and ball bondage can be a delight. Hemp rope is the perfect choice for this. And I have a fantastic resource for you, Julian, a novice, as well as for all you more advanced perverts. Check out all the great stuff at Twisted Monk. You’ll find everything you need, including some very informative how-to-videos. Look for the Twisted Monk banner in the V-Style Ball Spreadersidebar.

Again, safe play is happy play. Wrap the rope around your cock, and around each of your balls separately. Use the rope to stretch your sac. A little discomfort is desirable, but just don’t over do it. Remember the sensations will become more intense as your dick engorges with blood. Keep this kind of play to less than 10 minutes at a time. Watch for signs of distress — your dick will veer to the color purple and your balls will feel cool to the touch. When that happens, it’s time to loosen the restraints and move on to something else for a while.

If you really get into this you can find loads of more professional torture implements at Dr Dick’s Oxballs Stacker Ball StretcherStockroom. Look for the banner in the sidebar at the top of the page. There’s a whole department in my online store devoted to cock and ball toys. You might want to start with a ball stretcher or a cock and ball harness. Doesn’t that sound like fun?

CBT is great for livening up and extending a ho-hum jerk off session too. And here’s a tip: once you know what you like and how you like it; you can turn on your partner to the practices.

Speaking of partners, the novice perv might want to surrender his privates to a professional Dom. A well-trained mistress or master will be able to take you places you’ve only dreamed about. A pro Dom is also a great resource for the do-it-yourself kinda guy. Before you launch into uncharted waters, seek the advice of someone who has made the study of pain/pleasure his or her life’s work. But don’t expect to get this information for free.

Cock and ball play can be loads of fun — alone or with others. Just remember the mantra — safe play is happy play. Experimenting is fine, but if you get in over your head and you don’t know what the fuck you are doing, STOP. Go back to something more suitable to your skill set.

Good luck

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Penis politics: Sex, size and stereotypes in the gay community

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When it comes to penis size, gay men face a host of preconceptions about masculinity and race

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Recent studies have shown that actual penis size is smaller than men are claiming. According to the Journal of Sexual Medicine, the average male penis measures 5.6 inches when erect; the Journal of Urology puts it at a slightly smaller 5.08 inches. This is considerably smaller than previous numbers from Alfred Kinsey, Durex and the Definitive Penis study, which averaged 6.25 inches in their estimates. The difference between the two estimates: surveys like Durex’s rely on self-reporting, and men are likely to overestimate. As Tom Hickman wrote in “God’s Doodle”: “What is incontrovertible is that where men and their penises are concerned there are lies, damned lies, and self measurements.”

Just ask any gay man looking for a hook-up on Grindr. “If a guy tells you his size and you meet up, you realize he must have a different ruler,” said Noah Michelson, editor of The Huffington Post’s Gay Voices section. Michelson believes that the reason men are likely to overreport their penis size is because of the “cultural currency” the gay community places on having a large penis. “I think there’s something to do with internalized homophobia or insecurities about being a man,” Michelson said. “You want to have a big dick and you want to be with a big dick. You want to be with a ‘man.’”

Michelson argued it’s not just about having a large penis; it’s what that penis signifies. “Having a big dick means that you’re ‘masculine’ and you wield a lot of power, because we assign so much power to the phallus itself,” he told me. “You’re a dominator and a conqueror.” Michelson said that this idea is largely informed by pornography, a strong force in shaping desire in the gay community; but for those who don’t fit into that “porn culture,” it leads to a feeling of being left out. “It’s totally a lottery,” Michelson explained. “And you either win it or you don’t.”

According to Jaime Woo, author of the book “Meet Grindr,” which explores how men interact on mobile hookup applications, that game can have very negative consequences for queer men who find themselves on the losing side. That’s why the size issue can seem even more fraught in the gay community than among heterosexuals. “In gay male culture, your sexual worth is very tied to your worth in the community overall,” Woo said. “We don’t have a lot of structure in place for men who aren’t sexually valuable, and they disappear into the background. Gay men have enough issues already, and this is just another way for them to feel bad about themselves, if they’re not packing eight inches under their pants.”

Woo told me that looking for sex on Grindr “makes the expectations much more heightened.” “Grindr has really distorted peoples’ understanding of what average or normal is, and the fact that people can ask if six or seven inches are too small — it’s jaw dropping,” Woo said. “You can be very picky because there is something better around the corner, someone bigger or hotter and someone more your type. It creates a very narrow band of desire.”

Huffington Post writer Zach Stafford argued that in order to hook up, we’re commodifying ourselves for sexual consumption. “On Grindr, you’re literally putting someone in a box,” Stafford explained. “The app’s layout is an actual shelf, like you would see in a grocery store.” In order to participate on the site, Stafford said that you have to learn how to market yourself by those confines. “It’s like being a book on Amazon,” Stafford told me. “You give yourself a little cover and write your summary. You make yourself a product, and when you’re selling yourself, you always go bigger.”

Stafford said our fascination with penis size is inherently tied to capitalism. “Studies have shown that people with larger penises make more money,” Stafford explained. “It’s power in our pants.” Stafford also explained that the correlation between sex and power leads to a skewed power dynamic between tops and bottoms. Research shows that bottoms have smaller penises on average, and are more likely to have penis anxiety and low self-esteem.  In an essay for the Huffington Post, Stafford called it “Top Privilege.” Stafford wrote, “In this line of thought, bottoms are seen ‘less than,’ ‘feminine’ or ‘the woman’ because they are the taker of the phallus.”

But it’s not just an issue of money and gender. Race also plays a large part in how gay men read each others’ bodies, especially for black and Asian men, stereotyped at the ends of the size spectrum. Stafford, who is multiracial, said that men will often approach him in bars to ask about his penis, expecting him to conform to the stereotype. “It creates an enormous amount of pressure for black men,” Stafford stated. “Black men are only seen as a tool — a tool of building and a tool of fucking. They’re reduced to a big penis.” In his case, Stafford said men often fall into two camps: “Either white people look at me as a black man with a big dick, or they see me and fetishize me — they want to dominate me.”

Jay Borchert has had the exact opposite experience. A doctoral candidate at the University of Michigan, Borchert (who is white) has frequently dated men of color, causing his romantic experiences to be reduced to a fetish. “People make remarks that I must be in it for the dick,” Borchert told me. “Why can’t I be looking for ass? Why can’t I be looking for mouth? Why can’t I be looking for a person?” People sometimes assume that Borchert adopts the “bottom” role in his sexual relationships, which isn’t the case. Borchert sighed, “It was really frustrating because there’s more to dating and relationships than penis.”

Due to his ethnicity, Thought Catalog writer John Tao has also found himself being put in a box in the bedroom. “Because I’m Asian, I’m automatically categorized as being a bottom,” Tao said. “There’s a perception that I wouldn’t want to top.” Because of this, Tao said that’s the role he’s most often performed in sexual relationships. “All of these people think I’m a bottom, so I’ll just be a bottom,” Mr. Tao explained, “You have to be careful because we internalize these stereotypes about ourselves. Your gay Asian friend might identify as a total bottom, but that could be years of societal expectations.”

Justin Huang, who blogs about his experiences being gay and Chinese at I Am Yellow Peril, agreed that the baggage around penis size can be particularly harmful for Asian-American men. In school, Huang’s friends would often tease him about what they assumed was the size of his penis, which was difficult when coming to terms with his sexual identity. “For a long time, I thought I had a small penis,” Huang explained. “It’s amazing what your brain can train you to see. I didn’t have a lot of respect for my penis. Gay men are emasculated already, so when you’re gay and Asian, you feel doubly emasculated.”

Huang told me that when you’re Asian, you’re expected to perform the stereotype, meaning that guys are very curious to see what’s inside your pants. “I’ve been in straight bars using the bathroom where a guy will lean over and look at my dick, just to see if what they say is true,” Huang said. But Jaime Woo argued that the same isn’t true for white men, whose penis size isn’t policed in the same way. “White men are considered the sexual default, so you’re allowed to have some variability,” Woo said. “White men get to be anything and everything, and there’s no presumption there. So for white men, a big dick is a bonus.”

Huang also argued that these stereotypes are a symptom of our lack of sex education and lack of knowledge about our bodies. “We’re told to hide our penises,” Huang said. “It’s a form of sexual oppression we don’t talk about. You see boobs everywhere. You don’t see penises anywhere, not even HBO. It’s something that’s scandalous and cloaked.” Because of the shame surrounding invisibility, men often place too much emphasis on something so small. “When I think about the guys I’ve been with, I don’t remember the penises,” Huang said. “I remember the boy. A penis doesn’t smile. A penis doesn’t look into your eyes. A penis can’t wrap its arms around you.”

Instead of holding out for an unrealistic fantasy, Justin Huang believes gay men should start embracing each other for exactly who they are. “Gay men need to stop expecting each other to be porn stars,” Huang said. “If you dump a guy just because of his penis size, you are an asshole. So if you love your man, tell him that you like his penis. After all, when you’re dating a guy, you’re dating two people: You’re dating him and you’re dating his penis. We need to start valuing and appreciating both of them.”
 
Complete Article HERE!

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Pesky Pronouns

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Name: Lynn
Gender: Female
Age: 19
Location: Eugene, OR
I have a friend who is driving me (us) crazy. She is my age and we’ve been best friends since grade school. Last year I came out to her as a lesbian and she was very supportive and loving. This year it’s her turn. She cut her hair really short and now only wears men’s clothes. Thing is, she’s not gay, or lesbian. In fact, she doesn’t have a boyfriend or a girlfriend. As far as I know she’s still a virgin. She told me that she’s gender queer. I was like, OK cool. Then she changed her name and wanted all her friends to call her by her new gender-neutral name. I was like, OK cool. Now she wants us to use gender-neutral pronouns—they, their, and them when referring to “her.” This just sounds dumb. I want to be loving and supportive of her, like she was for me, but I don’t understand what’s going on. It’s like this whole thing is an act, like she is trying to see how much attention she can get. A lot of our friends have just given up on her, but I don’t want to do that. At the same time it’s like she’s mocking our trans friends who have real gender concerns. Am I being a dick for not wanting to go along with this?

Curious word choice there, young lesbian Lynn. Are you being a dick? Hell, I don’t know. What I can say for certain is, if we were being totally politically correct, we wouldn’t use euphemisms for our genitals in a derogatory way, right? Luckily, I’m not the least bit PC as you will discover from my comments below.gender-fuck

The question you raise in your email is a thorny one and I’m not sure I know how to respond. Gender is the new hot button issue and it is rapidly becoming the litmus test for PC crowd. As you suggest, it sometimes looks as though some folks are just trying to get attention or see how much the traffic will bear.

I’m going to be pretty self-referential in my response because I feel like I’ve been here before. Let me explain.

When I was about your age and into my early 20’s the modern gay lib movement here in the US was just finding its footing. Stonewall had just happened and those of us on the sexual fringe were tying to come up with a new vocabulary with which to talk about ourselves. No one I knew liked the term homosexual for obvious reasons. Some of us, myself included, preferred the term, homophile. The difference being one was about loving, the other was about sex. That term didn’t catch on, but “gay” sure did. I was fine with that, even though it wasn’t my first choice. As I began to take a closer look at my sexual orientation and identity, I became a bit more radical; gay just didn’t cut it anymore. I began to embrace the term “queer.”

look!When I was a boy, the term queer, often directed at me because I wasn’t like the other boys, was hate-filled and hurtful. It stung and I was ashamed. By my mid 20’s, however, I was no longer ashamed. In fact, I was full of a new found fervor that was connected to my new found identity as a sexual outlaw. I know for certain that my radicalness was a little off-putting to some people, even people who wanted to love and support me.

After I passed through my militancy stage, I continued to use the term queer to describe myself as a way of showing the world that I had reclaimed and detoxified the word that once brought me shame. It became my own personal badge of honor.  Maybe you’ve had a similar ark in your coming out, Lynn.

The curious thing is I’ve lived long enough to see the term I fought so hard to reclaim morph yet again. Nowadays, when someone self-identifies as queer, more often than not, it has to do with gender; it no longer has a strong sexual connotation. I feel a little bummed about this because one of my favorite words has been coopted by another group of people.  But that’s the nature of language, right?Gender-Outlaws6

Over the decades since I first began to struggle with who I was and how I would talk about myself to others, I’ve seen numerous fracturing of the solidarity we sexual outlaws might have had. There was a virulent strain of lesbian separatism that cropped up in the mid 70’s. But most of that has dissipated since. And there was the radicalism that came with HIV/AIDS, which turned quiet, unassuming, cocktail sipping homos into fearless street fighters. That too has played itself out. In fact, now that marriage equality is all the rage, some of us old queers are asking if it’s still possible to be a sexual outlaw by just being gay. I fear not. Apparently, gender benders are the new sexual outlaws. OK, my time has past; I get it. I have no hard feelings, but I do have a wistfulness for days gone by.

It’s also been my experience that some of us, and I include my younger self in this category, have an uncanny ability to alienate loads of people with our politics. That can be a good thing, but radicalism can, and often does, alienate those who would naturally be our allies as well as some of those who struggle next to us. There’s nothing more devastating to a popular movement than having a bunch of edgier-than-thou folks setting themselves up as the thought police. When this happens, as it always does, it suggests to me that we are more interested in making a point than making a connection. This is a particularly acute problem for the newly liberated crowd, often found on college campuses. They are flush with indignation as they discover that life is not fair. They tend to use the scattergun approach when doling out their fury regardless if those around them are deserved of their wrath or not.

fuck genderThe current incarnation of the gender liberation movement suffers from a lot of the excesses that other liberation movements have experienced before it—intolerance and dogmatism among them. The thing is, gender-fuck has a long history and an honored place in sexual politics. However, in the past, this has mostly expressed itself in street theater. Nowadays, there is precious little humor among the new gender warriors, and very few of these zealots can laugh at themselves. That tells me we’re all in for a very rough ride ahead.

I know how important a shift in vocabulary is to making the dominant culture see its oppression, but the pronoun thing is just awkward. For one thing, there’s no agreement on what pronouns to use for those who are rallying for gender neutrality. Some people militate for they, their, and them. Others want the even more extreme “ze,” pronounced as the letter zee. And “hir,” pronounced here. As in, “Ze went to the store and bought hirself an ice cream cone.” Well, if you wanna do that to the language go right ahead, but I refuse!

Besides, are we just supposed to use these twisted pronouns when the gender warrior is in our company, or are we to alter our vocabulary even when they aren’t around? Try using they, their, and them when referring to someone who isn’t present. Confusion will reign.gender neutral pronouns

Lynn, I don’t know your friend so I can hardly make a call on whether your friend is being authentic, disingenuous, or histrionic. But I don’t think you should beat yourself up if you draw the line at a pronoun shift. If your friend takes offense, as well your friend might, you could always compromise and use no pronouns ever in relation to your friend. Simply use your friend’s chosen name each time a pronoun might serve you better. In time, this will surely get exhausting for both you and your friend. But maybe this exercise will help your friend see that you are not the enemy and maybe your friend will then cut you a little slack.

Good luck

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Learning the ropes

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Name: James
Gender: Male
Age: 19
Location: Alaska
I am gay. I still have trouble saying that because of my very conservative upbringing, but that is not what I need help with today. I had my first few sexual encounters the other week with this great understanding, older guy. When he was blowing me it felt great, however I wasn’t able to cum during the oral sex. Is this normal? And is there anything I can do to change that? Thank you so much for any help, and the chance to say something to someone about being gay. I don’t get to talk about issues in this genre because of the taboo-ness of the issue. Thanks a lot- James

Wow, sorry to hear you’re living in such a repressive environment, pup. I hope that changes for you soon. Just remember, change is gonna begin with you. The longer you put up with the repression the harder it will be to break its grip.

Coming out is rarely a breeze for anyone. This is especially true for those, like yourself, who were raised in a conservative home. But then throwing off the shackles of oppression, however they present themselves, will make you a much better person in the long run. Like the old saying goes; “If you allow someone to control your sexuality, you allow that person to control all of you.” So nothing reverses the repression quicker than exercising your sexuality on your own terms.

As to the oral sex question you raise, I’ve written a whole lot about that already. You might want to glance over to the sidebar and look for CATEGORIES pull down menu. Look for the main category — Sex Therapy. Then look for the subcategory — Ejaculation Concerns.You’ll find a load of written postings and podcasts.

The gist of what I’ve had to say about this is; it’s not uncommon for a guy not to get off with just a blowjob. This is particularly true for someone who is new to the whole hummer thing. There’s also the distinct possibility that the guy doin the blowin’ may not be a particularly talented cocksucker. It happens! It happens a lot, believe me.

That being said, there are things you can do to change this if that’s what you really want. First and foremost, you need to communicate with your partner on how he’s doing down there. Ya see most of us guys get real used to the feel of our hand on our wang while jerkin-off. After years of practice we get our stroke down to a science. We know exactly when to apply more pressure, or loosen our grip. We know exactly when to speed up the stroke and when to ease off. We know exactly when to yank on our balls or stick a finger in our ass and diddle our prostate. We know all of this because our body is giving us constant feedback all the time we’re playin’ with ourselves.

On the other hand, the cocksucker between our legs isn’t gettin that kind of immediate sensory feedback, so he’s not gonna know what to do when. That is, unless you tell him. And it’s really ok to give the guy a little direction. A talented cocksucker, of course, will already know how to ask you for feedback. After all, he’s new to your cock and his experience tells him that all cocks respond the same why to the same stimulus.

Another thing you can do is relax. There’s not a whole lot of “shoulds” when it comes to sex. So the more relaxed you are the more you will be able to enjoy the pleasure. If your mind is all busy with dumb shit like — oh my god, I’m not gettin off, what must he think of me? — then you’re not in the moment and the pleasure is wasted on you.

Finally, the best way to learn how to receive a good blowjob is to become a fabulous cocksucker yourself. Smokin’ you some fine pole is an art form. It’s way more than simply than rappin’ your lips around a bloke’s dick. The more you understand about superior cocksucking the better you’ll be at guiding your partners through the fine points of eatin’ you meat. So get out there and get some experience.

Not sure what to do when faced with a big beautiful baloney pony? Well, you’re in luck. Check out my sexual enrichment tutorial: So Ya Wanna Be A World-Class Cocksucker …OR HOW TO GIVE THE PERFECT BLOW JOB.

Good Luck

Hey dr dick! What’s that toll-free podcast voicemail telephone number? Why, it’s: (866) 422-5680. DON’T BE SHY, LET IT FLY!

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What gay trans guys wish their doctors knew

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Vancouver study peers into the lives and troubles of trans MSM

Sam Larkham organizes sexual health clinics across Metro Vancouver with the Health Initiative for Men (HIM). He says he was once referred by his doctor to a trans health care clinic that had been closed for years.

By Niko Bell

Speaking to gay and bisexual trans men, the word “invisibility” comes up a lot. Invisibility in the bathhouse and on dating apps, invisibility among cisgender people, straight people, trans people and gay people. And, too often, invisibility in the doctor’s office.

“I have tried just going to walk-in clinics and stuff like that to ask questions or request tests,” one trans man recently told researchers in Vancouver. “And I just found the doctors were generally confused about me and my body. And I had to go into great detail. That made me not so comfortable talking to them about it because they were just kind of sitting there confused.”

“People have tried to talk me out of testing . . . saying I was low-risk behaviour,” another man told the researchers. “They didn’t understand my behaviour really. . . I’ve had practitioners as well say they don’t know what to do; they don’t know what to look for.”

Both men were speaking to researchers for a new study on the sexual health of trans men who have sex with men — a group social scientists know remarkably little about. Many of the men spoke about being on the margins of mainstream culture, gay culture and of the healthcare system.

It should be no surprise, then, that the study happened almost by accident. When PhD student Ashleigh Rich started work with the Momentum Health Study — a five-year, in-depth research project on the sexual health of men who have sex with men (MSM) conducted out of the BC Centre for Excellence in HIV/AIDS — she never intended to write a paper about trans MSM.

But a small group of trans men volunteered for the study, some pointing out ways the Momentum researchers could change their surveys to be more inclusive.

There were too few for quantitative research — only 14 — but Rich asked if they would sit down for an hour and talk about their experiences. Eleven agreed.

The result is a slim, 11-page paper that hints at a world of things we don’t yet know about transgender gay and bisexual men. We do know they form a large part of the trans population; nearly two thirds of trans men say they are not straight. We also know trans MSM participate in the same rich world of sexuality as other men who have sex with men — from dating apps to anonymous sex to sex work and a broad range of sexual behaviour.

We don’t know much about trans MSM risk for HIV; estimates range from much less than cisgender gay and bi men to somewhat more. We also don’t know much about how a combination of stigma, invisibility and limited healthcare options may be affecting trans men’s health.

Rich is cautious about drawing any broad conclusions from her study. Not only is it a tiny sample, but the men she spoke to are also mostly urban, white and educated. This study was less about answering questions, and more about figuring out which questions to ask.

A few themes, though, emerge clearly. One is that trans MSM often find themselves falling through the cracks when it comes to sexual health. Doctors are increasingly aware of how to talk to gay men, but don’t always see trans gay men as “real” MSM. They assume trans men are heterosexual, or fail to bring up sexual health altogether.

Some doctors give trans men information on PrEP — a preventative anti-HIV medication that can drastically reduce the risk of contracting HIV if taken every day — based on studies on cisgender men, without checking to see if different anatomy requires different doses. When trans men come in for HIV tests, they are sometimes urged to get pap smears instead.

“We come in with specific issues we want to talk about in a health care consult, and sometimes once people discover we’re trans they’ll want to do a pregnancy test or something,” says Kai Scott, a trans inclusivity consultant who collaborated on the study with Rich. “And we’re not there for that. They’re giving us things we don’t want, and not telling us the things we do need to know.”

Sam Larkham, a trans man who organizes sexual health clinics across Metro Vancouver with the Health Initiative for Men (HIM), says he was once referred by his doctor to a trans health care clinic that had been closed for years. Experiences like that make him think the best path for trans MSM is to rely on queer-focused health care providers like HIM.

“It would be ideal if it were the whole medical system, but that’s impossible,” Larkham says. “I think we have to look at what we can do, and that’s have specific places where we have nurses who are well trained to handle trans MSM. I think that’s the more doable thing. I would love to have every clinic be culturally competent, but that’s not the reality and never will be.”

Scott is more sanguine. He points to Trans Care BC, a provincial health program that has pushed for more education for doctors. Education needs to happen on both fronts, Scott says, among MSM organizations and in the health care system at large.

Lauren Goldman is a nurse educator for Trans Care BC. Since she was hired last fall, she’s been giving workshops to healthcare providers on how to treat trans patients. For now, though, the workshops are aimed at small groups of sexual health professionals, such as at the BC Centre for Disease Control or HIM. Goldman wants the program to expand to include everyone.

“We know trans patients are accessing care through a number of places all across the province,” she says. “We want everyone to have access to this information as soon as possible.”

Goldman says Trans Care is designing an online course that could bring trans cultural competency to primary care doctors everywhere as part of mandatory continuing education. Trans Care has also designed a primary care “toolkit” for doctors, and is in talks with UBC’s medical school about including trans-focused sexual health education for doctors in training.

Without specialized knowledge, Goldman says, there’s a lot doctors can miss. Testosterone can make vaginal tissue more sensitive and inflexible, for example, meaning trans men might have special difficulties with genital sex. Bacterial vaginosis is more common, and the usual antibiotics given to cis women may not solve the problem. Vaginal and rectal tissue may need different doses of PrEP to be effective.

And, most importantly, doctors need trans patients to know they will be heard.

“We need to be providing really obvious cues that show people that our services are trans inclusive,” Goldman says. “Including how we design our services, how we market our services, how we educate our clinicians, what signs we hang up, letting people know that our clinicians have a greater understanding of gender diversity.”

While Goldman is educating doctors, the trans men Rich studied were already very well educated about their own sexual health. They told Rich about careful risk assessments they make around sex, sharing information with other men, and advocating for STI screening to their reluctant doctors.

One man described slipping in HIV tests while getting regular testosterone-level screening: “Yeah, oh, I’m already getting blood drawn. I probably need to get tested, let’s just draw two more vials for HIV and syphilis.”

It’s not surprising that many trans men are so health-conscious, Scott says. “We’ve had to be champions of our own bodies for a while, and so that ethos carries through when it comes to health information.”

But it would be a mistake to overstate how safe trans MSM are, he adds. For one, the urban, white and well-educated men in Rich’s study may be more likely to have access to resources and care than less wealthy or more rural trans people. Also, the very reason trans MSM seem so safe might be because they aren’t getting the opportunities for sex they want.

“To some extent, we’re still on the sidelines,” Scott says. “I don’t think that systemic rejection should be the means of HIV prevention for trans and nonbinary people. We’re dealing with a lot of rejection, and so I don’t think we’ve really had the opportunity to be exposed to that risk.”

The theme of rejection is echoed frequently by the study subjects.

“I remember meeting this one guy at a friend’s party and we were flirting the whole time,” one participant recounted. “He was like, ‘Oh we should totally go for a beer’ and so we connected and then I told him I was trans and he was like, ‘Oh I’m not looking for anything.’”

“Cis men often shut down immediately, out of a sort of fear of the unknown, and being unaware of what can and can’t happen,” Scott says. “They can assume all trans guys are bottoms, which isn’t true.”

Constant rejection can wear trans men down, Larkham says. Not only does it damage mental health, but constant rejection can weaken trans men’s resolve to negotiate sexual safety.

Many trans men, the study notes, rely on online hookup sites, where they can be upfront about being trans, and avoid rejection by anyone who isn’t interested.

The burden of rejection is one reason trans MSM need better mental health services too, Larkham says. Too many men show up to sexual health clinics after being exposed to sexual risks. Mental health support, he thinks, could reach people earlier.

But again, Scott strikes a positive note. “It’s a source of celebration to me that despite huge barriers we’re still having the sex that we want,” he says.

In the end, the clearest message to emerge from Rich’s study is that there’s a lot more to learn. She hopes to get more answers from the next stage of the Momentum study, which will recruit a larger sample of MSM from across Canada. That study, she hopes, will be large enough to deliver the kind of precise, quantitative answers that this one couldn’t.

Scott is also eager to move forward.

“There’s so much you want to pack in and so much you want to report on,” he says. “There’s such a dire need to research these issues. People are really hurting, and I really feel that. But you’ve got to take it one step at a time.”

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